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Patient Health Record

Name

Birthdate

The following information is requested to provide us with knowledge of your feelings and general health background. This is a necessary part of any thorough examination, and, of course, this information will be held confidential.

Medical Health

General health (please check)

Excellent Good Fair Poor

Name of your physician

Address and phone number

Last complete physical / If so, for what reason

Are you taking any medication now?

Yes No

For what purpose

List all medications

List all Allergies

Have you ever been hospitalized? If so, give name or hospital, reason and dates

Women: Are you pregnant?

Yes No

How long?

Consent

The undersigned hereby authorizes the doctor to perform all the necessary diagnostic procedures deemed appropriate to make a thorough diagnosis of the patient’s dental or oral-facial needs including x-rays, study models, photographs, medications, and the use of local anesthetic agents.

I also give permission for the use of photographs and records made in the process of examination and treatment to be used for purposes of education, or publication in professional journals.

PATIENT SIGNATURE (OF PARENT/GUARDIAN OF CHILD)

Click to Sign

Date:-------------

General Information

Sex

Male Female

Street Address

City / State / Zip Code

Home Phone No. / Cell Phone No.:

Email/text confirmations?

Yes No

Patient/Parent/Guardian SSN

Parent/Guardian Name

Same address as patient?

Yes No

Insurance Information

Insurance Company / Group No.

Employer

Insured

SSN/Alt ID # / Insured’s DOB

Person responsible for account

Relationship

Who should we contact in case of an emergency?

Relationship / Phone No.

Who were you referred by

Protected Health Information

I authorize Raymond Skowronski, Jr., DDS, PC to release the following Protected Health Information concerning the patient.

Past, present, and future claims information;
All dental treatment rendered or treatment planned
All account (financial) information

Please identify the person(s) with whom the member’s Protected Health Information may be released to and their relationship.

A copy of the Privacy Notice is available for me to review. I hereby consent that my Protected Health Information may be used and disclosed for treatment, payment and all healthcare operations. I also understand that I may request restrictions and or revoke consent, in writing, to the office.

(Signature of Patient or parent/guardian)

Click to Sign

Date:-------------

PATIENT REQUEST TO RELEASE PROTECTED HEALTH INFORMATION

I do hereby give permission to

to copy my x-rays and send them to the provider of my choice.

(Signature of Patient or parent/guardian)

Click to Sign

Date:-------------

Please send records to:

Provider name

Street Address

City / State / Zip Code

Office Phone No.

Email address (if applicable) to forward x-rays

truForm by PBHS

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Patient Health Record

Patient Health Record

Medical Health

Have you ever been informed that you had or may have had any of the following:

Dental Health

Consent

Consent

Click to Sign

General Information

General Information

Insurance Information

Insurance Information

Protected Health Information

Protected Health Information

Click to Sign

PATIENT REQUEST TO RELEASE PROTECTED HEALTH INFORMATION

Click to Sign

PBHS truForm is best utilized in portrait mode.

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Main Header

Patient Health Record

Patient Health Record

Medical Health

Have you ever been informed that you had or may have had any of the following:

Dental Health

Consent

Consent

Click to Sign

General Information

General Information

Insurance Information

Insurance Information

Protected Health Information

Protected Health Information

Click to Sign

PATIENT REQUEST TO RELEASE PROTECTED HEALTH INFORMATION

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.